Thursday, April 24, 2014

Quality to the Next Level

Medicare Appeals and Grievances

Your Medicare Appeal Rights:

You have the right to appeal any decision about your Medicare services. If Medicare does not pay for an item or service you have been given, or if you are not given an item or service you think you should get, you can appeal.

Appeal Rights Under the Original (Fee For Service) Medicare Plan:

If you are enrolled in the Original Medicare Plan, you can file an appeal if you think Medicare should have paid for, or did not pay enough for, an item or service you received. If you file an appeal, ask your doctor or provider for any information related to the bill that might help your case. Your appeal rights are on the back of the Explanation of Medicare Benefits or Medicare Summary Notice that is mailed to you from a company that handles bills for Medicare. The notice will also tell you why your bill was not paid and what appeal steps you can take.

Transfer of Appeal Rights

A beneficiary may decide to transfer his or her rights to appeal the claim to the Medicare provider that performed the service. For more information, please see: Transfer Appeal Rights (pdf document)

You are protected when you are in the hospital:

If you are admitted to a Medicare participating hospital, you should be given a copy of An Important Message From Medicare. It explains your rights as a hospital patient. If you are not given one, ask for it. The message tells you:

  • You have the right to get all of the hospital care that you need, and any follow-up care after you leave the hospital.
  • What to do if you think the hospital is making you leave too soon.

If you have questions about this, call 1-800-MEDICARE. If you ask a Quality Improvement Organization (QIO) to review your case, you may be able to stay in the hospital at no charge during the review. The hospital cannot force you to leave before the QIO makes a decision.

View and Download Medicare Forms

The appeals process under original Medicare (Part A and B) is authorized by section 1869 of the Social Security Act. Procedures are set forth in the Code of Federal Regulations (CFR) at 42 CFR 405, subpart I (sections 405.900 - 405.1140). For more information regarding the appeals process, please visit the CMS website.

Part A Appeals

This section provides specific information for Part A services billed to a Part A MAC:

  • Inpatient hospital
  • Outpatient hospital
  • Skilled Nursing Facility
  • Home Health Services
  • Hospice

Part B / DME Appeals

This section provides specific information for Part B and Durable Medical Equipment (DME) services billed to a Part B MAC.

These services include:

  • Physicians’ services
  • Non-physician practitioners’ services
  • Clinical laboratory services
  • Durable Medical Equipment (wheelchairs, hospital beds, walkers, oxygen, etc.)

Helpful Links

 

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